Acute coronary syndrome (ACS) during pregnancy is rare but may be associated with high risk complications. Approximately 150 myocardial infarctions (MI) during pregnancy have been documented in literature worldwide, but we didn’t find one with myocardial aneurysm. We describe 2 patients with acute MI; both with ST segment elevation (STEMI), 1 case complicated with heart failure, formation of a myocardial aneurysm and broad QRS arrhythmia; another with uncomplicated course, and their anesthetic management during delivery. Acute MI is rare in reproductive age usually developing in women with cardiovascular risk factors. There is concern about its rising incidence due to the increase of average maternal age. Our cases show that there might be some undiscovered risk factors for pregnancy related myocardial infarction

Ljiljana Mihaljević

Renata Curić Radivojević

Slobodan Mihaljević

English

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447described resting substernal chest pain with weakness, shortness of breath and radiation back between shoulders. On arrival at the emergency department her electrocar-diogram (ECG) showed normal sinus rhythm with ST-el-evation in leads V2–V6, I and aVL; her blood pressure (BP) was 90/60 mm Hg. She had been followed up by her obste-trician and had no history of hypertension, hyperlipidemia or diabetes before or during pregnancy. She is non smoker. Her body mass index (BMI) was 23.87 kg/m2 at time of this event. Her family history is free for cardiovascular dis-eases. She only had a partial removal of an endocervical polyp a month before presentation in an outlying clinic. Her fi rst troponin T was positive (50.33 ng/ml; normal range is below 0.2 ng/ml). Transthoracic (TTE) and trans-esophageal (TEE, done with all due precautions) echocar-diography excluded aortic dissection. TTE revealed hypo-kinesia of interventricular septum, front wall and apex of a heart. She was transferred to the cardiac intensive care unit (ICU). Cardiac catheterization with possible inter-vention was performed and demonstrated 100% occlusion of left anterior descending (LAD) coronary artery, but in-tervention was unsecsesfull because the wire couldn’t pass the dissected part of a vessell. Special precautions were taken during the procedure to protect the fetus, such as Myocardial infarction (MI) during pregnancy is rare but is often associated with signifi cant maternal mortality. Approximately 150 MI during pregnancy have been docu-mented worldwide1. The reported incidence varied from 0.6 to 1 cases per 10,000 deliveries. Maternal mortality after MI vary from 5.1 to 37%. Pregnancy has been reported to increase the risk of MI by 3–4 times2,3. Acute MI occurs more commonly in multigravida and women older than 30 years of age. Delivery within 2 weeks of the infarct is also associated with s poorer maternal prognosis owing to the increased myocardial demand during labor or surgery.We present 2 patients with acute coronary syndrome (ACS) during gestation, both with ST-segment elevation (STEMI), one with severe complications, another with un-complicated course, and different anesthetic and obstetri-cian management of delivery according to the clinical status of a patient.Case ReportCase 1A 32-year-old healthy nulipara at 20 weeks of gestation presented to an outlying hospital with chest pain. She Coll. Antropol. 39 (2015) 2: 447–450Case repor Acute Coronary Syndrome with ST-segment Elevation in Pregnancy: Anesthetic Management of DeliverySlobodan Mihaljević1, Renata Curić Radivojević2 and Ljiljana Mihaljević11 University Hospital Centre Zagreb, Department of Gynaecology and Obstetrics, Zagreb, Croatia2 University Hospital Center Zagreb, Department of Anesthesiology and Intensive Care Unit, Zagreb, CroatiaA B S T R A C TAcute coronary syndrome (ACS) during pregnancy is rare but may be associated with high risk complications. Approxi-mately 150 myocardial infarctions (MI) during pregnancy have been documented in literature worldwide, but we didn’t fi nd one with myocardial aneurysm. We describe 2 patients with acute MI; both with ST segment elevation (STEMI), 1 case complicated with heart failure, formation of a myocardial aneurysm and broad QRS arrhythmia; another with uncompli-cated course, and their anesthetic management during delivery. Acute MI is rare in reproductive age usually developing in women with cardiovascular risk factors. There is concern about its rising incidence due to the increase of average maternal age. Our cases show that there might be some undiscovered risk factors for pregnancy related myocardial infarction.Key words: acute coronary syndrome, STEMI, myocardial infarction, pregnancy, delivery, anesthesiaIntroductionReceived for publication February 1, 2014448S. Mihaljević et al.: STEMI in pregnancy, Coll. Antropol. 39 (2015) 2: 447–450draping the maternal abdomen with a lead shield and per-forming continuous electronic fetal monitoring. The pro-cedure was otherwise unaltered to accommodate the pre-gnancy. Cardiac surgeon was consulted and recomended conservative treatment rather than high risk coronary artery bypass grafting (CABG) surgery because of advan-ced pregnancy. After the procedure, the patient was placed on unfractionated heparin, glycoprotein inhibitor, clopido-grel, aspirin and bisoprolol. Immediately after catheteri-sation, she had multiple episodes of spontaneously resol-ving nonsustained ventricular tachycardia and heart failure. When stable, she was transferred to the antepar-tum unit for continued observation. Serial TTEs reveled thin hypokinetic to akinetic interventricular septum with anteroapicoseptal myocardial aneurysm and reduced ejec-tion fraction of left ventricle (EF LV) 41%. The patient was discharged on clopidogrel 75 mg daily, aspirin 100 mg da-ily and β-blockade with bisoprolol 2.5 mg daily, with advice to do an elective cesarean section delivery under general anesthesia to avoid stress responses due to the vaginal childbirth and hypotension after regional anesthesia be-cause of a reduced EF LV of 41% and myocardial aneu-rysm (see fi gure 1.). After 7 days period of discontinution of clopidogrel and aspirin, bridged with low molecular weight heparin (LMWH) subcutaneously (sc), an elective cesarean section was indicated by an obstetrition at 38 weeks and 1 day of gestation. Patient was premedicated with 10 mg metroclopramid intravenous (iv) an hour befo-re surgery. After placing an arterial line for invasive blo-od pressure monitoring, induction was made with 1 μg/kg of fentanyl, 0.3 mg of etomidate and 1 mg/kg of rocuroni-um. Maintenance was done with 1 MAC of sevofl urane in gas mixure of oxygen and nitrous oxide until the umbilical cord was cut, sevofl urane was discontinued. Ten minutes after intubation, a 3.520 g baby was born with Apgar sco-res of 10 and 10 (arterial cord gas showed pH 7.27). After that 5 mg of midazolam, 1 μg/kg fentanyl, 5 international units (IU) of oxytocin (as the obstetrician requested) in bolus and 15 IU in slow intravenous infusion were added. During anesthesia she was hemodynamically stable with her sistolic BP kept between 109–128, diastolic BP between 60–80 mmHg and heart rate from 70–86 bpm. She was awoken and extubated in the operating theatre and then transferred to ICU for further hemodynamic monitoring and evaluation. Her medical regimen included oxygen, LWWH sc, β-blockade and analgesia. On the fo-urth day postpartum she was transferred to the ward and then to cardiology for futher treatment. The patient and her child did well on follow-up.Case 2A 35-year-old pregnant woman (gravidities 2) at 30 weeks of gestation presented to emergency department with chest pain. She described substernal chest pain dur-ing cooking, with weakness and radiation back between shoulders. Pain resolved spontaneously within 30 min-utes, but repeated once again afterward. She was weak and collapsed without losing conscious. Her fi rst ECG at ambulance showed ST elevation in leads I and aVL. On arrival at the emergency department of an outlying hos-pital, she had no pain. Her second ECG showed sinus rhythm with HR 113/min. Repeated ECG after an hour (about 3 hours after fi rst chest pain) showed normal sinus rhythm with Q wave in leads I and aVL and negative T wave in same leads. She had been followed up by her ob-stetrician and had no history of hypertension, proteinuria or diabetes before or during this and previous pregnancy. She is non smoker. Her BMI was 27.04 kg/m2, but this was during 30 weeks of gestation, when she gained 8 kg. Her family history is free for cardiovascular diseases. Her fi rst troponin I was positive (22.78 ng/ml; normal range is <0.03 ng/ml) and she was transferred to cardiac ICU. Medical regimen was conservative and included LMWH sc, β-blockade, clopidogrel and aspirin. TTE showed good EF LV 68% without akinesia and good valvular aparat-hus. Her postinfartion period was uncomplicated, cardiac enzims returned to normal and she was transferred to the antepartum unit for continued observation. Invasive pro-cedures havent been done because of abscence of signs of persistent ischemia and hemodynamic stability of patient. The patient was discharged on aspirin 100 mg daily and bisoprolol 1.25 mg daily.Fig. 1. Case 1: Transthoracic echocardiograph (TTE) showing thin interventricular septum with anteroapicoseptal aneurysm. Ejection fraction of left ventricle (EF LV) is 41%.449S. Mihaljević et al.: STEMI in pregnancy, Coll. Antropol. 39 (2015) 2: 447–450She was followed up by cardiologist and obstetrician who recommended a vaginal birth under epidural analge-sia and transferred to our hospital. After 5 days period of discontinution of aspirin and thromboprophylaxis with LMWH sc, elective induction of labour with oxytocin be-gan at 38 weeks and 4 days of gestation. She received an early epidural catheter at intervertebral space L3/L4, con-tinuous ECG; oxygenation, fetal heart rate monitoring and an arterial line. Epidural analgesia was done with two bolus doses, each containinig 10 ml mixture of 0.125% levobupivacain and 10 μg per ml of fentanyl. First dose was given before induction of labour and second after amniotomia. Five hours after the induction, the patient underwent a planned, uncomplicated vaginal delivery of a 4.280 g neonate with Apgar scores of 10 and 10. The patient was monitored in ICU for two days postpartum. Her postpartum course was unremarkable and ECG un-changed.DiscussionAcute MI in pregnancy is uncommon and bears the problem of misdiagnosis. About 150 cases have been pub-lished worldwide1. Lander et al.2, however, found in their study that pregnancy increases the risk of MI 3- to 4-fold. The highest incidence has been reported among multi-gravidas older than 33 years of age during the third tri-mester3. Anterior wall infarctions are the most common. Among the causes of coronary artery occlusion in preg-nancy there are four mechanisms: (1) rupture of very small coronary artery plaques (40%) and subsequent thrombus formation triggered by different events, e.g., hypertension; (2) plain coronary artery disease (8%); (3) dissection (30%) of coronary arteries (case 1 and 2 prob-ably) and (4) coronary artery spasms (13%) with or without arterial thrombosis due to enhanced vascular reactivity to angiotensin, norepinephrine and ergot derivatives that are used to control post-partum or postabortion hemorr-hage or to suppress lactation1,3. The second mechanism is rare among nonpregnant women, but is not uncommon in pregnancy3. The gold standard in the therapy of STEMI during pregnancy is immediate coronary angiography and percutaneous transluminal coronary angioplasty (PTCA) with or without stent implantation1,3. As the average ma-ternal age increases and assisted reproductive technology allows for very advanced maternal ages, it can be expect-ed that the incidence of MI during pregnancy will rise in the future1–4. Despite a known risk factors for ACS (hyper-tension, diabetes, smoking, family history, obesity, hyper-lipidemia, preeclampsia and eclampsia2,3,5) our cases show that there might be some undiscovered risk factors in pregnancy related ACS, because they were previously healthy women, one of who developed severe life threaten-ing complications. Prompt diagnosis and immediate ther-apy are necessary to lower the high mortality of mother and fetus.Gil et al.6 in their report published in 2005, preferred general anesthesia to ensure hemodynamic stability, bet-ter control of oxygen supply and to reduce oxygen myocar-dial consumption as there are no clear guidelines with respect to which anesthetic technique is the best in preg-nant women with MI. Roth et al.3 in their 2008 review stated that the mode of delivery in a patient with gesta-tional MI should be determined by obstetric considerations and the clinical status of the mother. An elective cesarean section and the presence of an appropriate medical team, including an experienced obstetrician, obstetric anesthe-siologist, cardiologist and pediatrician, allow better con-trol of the time of delivery and avoid a long and stressful labor. Vaginal delivery under epidural analgesia, on the other hand, eliminates the potential risks associated with anesthesia and a major surgical procedure that includes hemodynamic fl uctuations, larger blood loss, pain, infec-tion, respiratory complications, damage to pelvic organs, and potential unfavorable effects on future reproductive health3,7. An individual decision according to a clinical status of a patient is the key in optimal delivery.El-Deeb et al.9 in their 2011 review discuss about chal-lenges of ACS during pregnancy for many reasons. First, a rapid and accurate diagnosis of this condition will con-tinue to be a challenge for physicians owing to the relative rarity of this condition, misinterpretation of signs and symptoms and low level of suspicion. Second, pathophysi-ology of ACS is different in nonpregnant and pregnant women. Third, a challenge in the standardization of the current recommendation for the management of ACS de-pends on the pathophysiology of ACS, that is, the main cause of ACS in nonpregnant women, is plaque rupture and subsequent thrombus formation, while coronary dis-section is more common in pregnant women. Different etiologies of ACS during pregnancy make uniform recom-mendations very diffi cult. Most, if not all of the trials based on the management of ACS, excluded pregnant women, meaning that the use of such medications in preg-nancy is not evidence-based. Last, the risk of radiation during PCI is another challenge that may carry consider-able hazards to the fetus. Further studies are needed to minimize this risk9.The incidence of ACS is rising over the last decades. It usually develops in women with preexisting cardiovascu-lar risk factors; our cases show that there might be some undiscovered risk factors for developing pregnancy related ACS. Today’s researches should be concentrated on dis-covering those »invisible« risk factors for cardiovascular diseases in healthy pregnant women.Further more, current guidelines for the diagnosis and treatment of MI should be expanded to include pregnancy related MI. The screening and management of cardiovas-cular risk factors should be achieved before pregnancy8,9. The decision of optimal delivery has to be made individu-ally by a team of a cardiologist, an obstetrician and an obstetric anesthesiologist according to a clinical status of a patient.450S. Mihaljević et al.: STEMI in pregnancy, Coll. Antropol. 39 (2015) 2: 447–450R E F E R E N C E S1. HÄRTEL D, SORGES E, CARLSSON J, RÖMER V, TEBBE U, Herz, 28 (2003) 175. — 2. LADNER HE, DANIELSEN B, GILBERT WM, Obstet Gynecol, 105 (2005) 480. — 3. ROTH A, ELKAYAM U, J Am Coll Cardiol, 52 (2008) 171. — 4. DWYER BK, TAYLOR L, FULLER A, BRUMMEL C, LYELL DJ, Obstet Gynecol, 106 (2005) 1162. — 5. NA-BATIAN S, QUINN P, BROOKFIELD L, LAKIER J, Obstet Gynecol, 106 (2005) 1204. — 6. GIL S, ATIÉNZAR C, FILELLA Y, FERNÁNDEZ M, BORRÁS R, MIRANDA A, Int J Obstet Anesth, 15 (2006) 71. — 7. HANKINS GDV, WENDEL GDJR, LEVENO KJ, STONEHAM J, Obs-tet Gynecol, 65 (1985) 139. — 8. RUZIĆ A, MILETIĆ B, BALEN S, PERSIĆ V, TRAVICA-SAMSA D, RAKIĆ M, PEHAR-PEJCINOVIĆ V, HAJDIN J, VCEV A, LASKARIN G, Coll Antropol, 35 (2011) 161. — 9. EL-DEEB M, EL-MENYAR A, GEHANI A, SULAIMAN K, Expert Rev Cardiovasc Ther, 9 (2011) 505.R. Curić RadivojevićUniversity Hospital Centre Zagreb, Department of Anesthesiology and Intensive Care Unit, Kišpatićeva 12, 10000 Zagreb, Croatiae-mail: renata.curic@gmail.comAKUTNI KORONARNI SINDROM U TRUDNOĆI: ANESTEZIJA/ANALGEZIJA ZA PORODS A Ž E T A KAkutni koronarni sindrom tijekom trudnoće je rijedak, ali može biti povezan s teškim komplikacijama. Približno 150 srčanih udara tijekom trudnoće je opisano u literaturi širom svijeta, ali nismo pronašli niti jedan slučaj s posljedičnom aneurizmom srčanog mišića. Opisat ćemo 2 bolesnice s akutnim srčanim udarom s ST elevacijom, 1 slučaj kompliciran srčanim zatajenjem, nastankom aneurizme srca i aritmijom; drugi s nekompliciranim tijekom i anesteziološki pristup tijekom poroda. Akutni srčani udar je rijedak u reproduktivnoj dobi i obično nastaje u žena s pridruženim kardiovasku-larnim rizicima. Zabrinjavajući je porast incidencije kardiovaskularnih incidenata u ovoj populaciji zbog odgađanja trudnoće u kasniju životnu dob. Naši slučajevi ukazuju da se možda radi o nekim dosad neotkrivenim faktorima rizika za razvoj srčanog udara u trudnoći.

Acute Coronary Syndrome with ST-segment Elevation in Pregnancy: Anesthetic Management of Delivery

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